O&G · Gynaecological health — vaginal infections
Vaginal discharge — bacterial vaginosis, vulvovaginal candidiasis & aerobic vaginitis
Also known as Vaginal discharge · Bacterial vaginosis · BV · Vulvovaginal candidiasis · VVC · Aerobic vaginitis · Desquamative inflammatory vaginitis · Recurrent vulvovaginal candidiasis
Exam-exhaustive FRANZCOG fellowship topic on vaginal discharge: the normal vaginal physiology and its Lactobacillus-dominated microbiota; bacterial vaginosis (the Amsel criteria and the Nugent score reproduced verbatim, the CDC 2021 recommended and international regimens, the recurrence and suppression problem); vulvovaginal candidiasis (uncomplicated vs complicated, the species distribution, fluconazole and intravaginal azoles, the Sobel maintenance regimen for recurrent disease, non-albicans and boric acid); and aerobic vaginitis (the Donders definition, its distinction from BV, and its different treatment). Cross-links to pelvic inflammatory disease, the menstrual cycle and cervical screening. RANZCOG-primary, globally tagged to MRCOG, ABOG, FRCSC and MRCPI.
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Target exams
Red flags
- Vaginal discharge with cervical motion, uterine or adnexal tenderness is pelvic inflammatory disease — treat empirically, do not treat it as a simple vaginitis
- Discharge in pregnancy: treat symptomatic BV (preterm-birth association) but never give oral fluconazole — use topical azoles
- Treatment-refractory 'candidiasis' that is inflamed and purulent with a raised pH is not candida — think aerobic vaginitis or trichomoniasis, and look at the wet mount
- Frothy yellow-green discharge with a strawberry cervix is trichomoniasis — an STI needing partner treatment, not a topical cream
- Recurrent or non-albicans candidiasis, or refractory BV, warrants culture and speciation before more empirical cycles
A woman with vaginal discharge wants one thing: an answer, not a recurring mystery. The skill is in the pattern at the bedside — odour points to bacterial vaginosis, itch to candidiasis, and inflammation to aerobic vaginitis or an STI — confirmed by three cheap tests: pH paper, a drop of KOH, and a wet mount. Get those right and you will rarely send the wrong swab or give the wrong drug.[3][4]
Overview and definition
Vaginal discharge is the commonest gynaecological symptom in primary care. It is normal in most women and pathological in a defined few. The job is to separate the physiological from the pathological, then separate the pathological into its three dominant causes:[3][4]
- Bacterial vaginosis (BV) — a vaginal dysbiosis (anaerobes replace lactobacilli); the single commonest cause of pathological discharge worldwide.
- Vulvovaginal candidiasis (VVC) — overgrowth of Candida, usually albicans; an itch-and-curds picture with a normal pH.
- Aerobic vaginitis (AV) — a distinct inflammatory flora dominated by aerobic organisms (Group B strep, E. coli, S. aureus); easily confused with BV until you look down the microscope.[5]
Three other diagnoses must sit in your head alongside them, because each changes management: trichomoniasis (an STI), cervicitis (an STI until proven otherwise), and pelvic inflammatory disease (the upper-tract emergency that masquerades as "just discharge").[4]
References13ShowHide
- [1]Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med, 1983.PMID 6600371
- [2]Nugent RP, Krohn MA, Hillier SL Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol, 1991.PMID 1706728
- [3]Muzny CA, Balkus J, Mitchell C, Sobel JD, Workowski K, Marrazzo J, Schwebke JR Diagnosis and Management of Bacterial Vaginosis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines. Clin Infect Dis, 2022.PMID 35416968
- [4]Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep, 2021.PMID 34292926
- [5]Donders GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG, 2002.PMID 11845812
- [6]Vieira-Baptista P, Lima-Silva J, Pinto C, Saldanha C, Beires J, Martinez-de-Oliveira J, Donders G Bacterial vaginosis, aerobic vaginitis, vaginal inflammation and major Pap smear abnormalities. Eur J Clin Microbiol Infect Dis, 2016.PMID 26810061
- [7]Sobel JD, Wiesenfeld HC, Martens M, Danna P, Hooton TM, Rompalo A, Sperling M, Livengood C 3rd, Horowitz B, Von Thron J, Edwards L, Panzer H, Chu TC Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med, 2004.PMID 15329425
- [8]Sobel JD, Ferris D, Schwebke J, Nyirjesy P, Wiesenfeld HC, Peipert J, Soper D, Ohmit SE, Hillier SL Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to prevent recurrent bacterial vaginosis. Am J Obstet Gynecol, 2006.PMID 16647911
- [9]Bradshaw CS, Tabrizi SN, Fairley CK, Morton AN, Rudland E, Garland SM The association of Atopobium vaginae and Gardnerella vaginalis with bacterial vaginosis and recurrence after oral metronidazole therapy. J Infect Dis, 2006.PMID 16941351
- [10]Bitew A, Abebaw Y Vulvovaginal candidiasis: species distribution of Candida and their antifungal susceptibility pattern. BMC Womens Health, 2018.PMID 29902998
- [11]Fidel PL Jr, Yano J, Esher SK, Noverr MC Applying the Host-Microbe Damage Response Framework to Candida Pathogenesis: Current and Prospective Strategies to Reduce Damage. J Fungi (Basel), 2020.PMID 32168864
- [12]Neal CM, Kus LH, Eckert LO, Peipert JF Noncandidal vaginitis: a comprehensive approach to diagnosis and management. Am J Obstet Gynecol, 2020.PMID 31513780
- [13]Reichman O, Sobel J Desquamative inflammatory vaginitis. Best Pract Res Clin Obstet Gynaecol, 2014.PMID 25132275